비심인성 흉부 불편감을 가진 대상자에서 컴퓨터 기반 인지행동치료의 효과성 : 문헌 검토와 새로운 프로토콜 제안
Efficacy of Computerized Cognitive Behavioral Therapy in Individuals with Non-Cardiac Chest Discomfort : Review and Suggestions for a New Protocol
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비심인성 흉부 불편감(non-cardiac chest discomfort, NCCD)은 심혈관계의 이상이 없이 반복적으로 발생하는 흉통으로 정의된다. 흉통으로 응급실을 방문한 환자 중 50% 이상이 NCCD로 진단된다는 보고가 있을 정도로,1) NCCD는흉통의 대표적인 감별 진단 중 하나이다. 일반 인구의 유병률또한 약 20~30% 정도로 알려져 있다.2) NCCD의 원인으로는 위식도역류질환(gastroesophageal reflux disease)과 식도 및 내장기관 운동질환 등이 비교적 흔한 것으로 알려져있으나 원인을 규명하지 못하는 경우도 절반 이상인 것으로보고되고 있으며,3) 과호흡,4)5) 공황장애6) 등의 공존 정신질환및 스트레스,7) 통증에 대한 부적응적 인지(maladaptive cognition) 조절과 같은 정신·사회적 요인이 복합적으로 증상 발현에 영향을 줄 것으로 추정되고 있다.6)8) 대부분의 NCCD 환자들은 검사 결과에 이상이 없다는 사실을 받아들이지 못하고, 불필요한 검사 및 치료에 많은 의료비를 지출하게 된다.9) 국내의 경우 정확한 수치는 파악되지 않으나, 미국의 경우는 NCCD로 인하여 연간 130억 달러에 육박하는 의료비가 불필요하게 지출되는 것으로 집계되었다.10) 또한NCCD 환자의 절반 이상이 지속적인 통증에 대한 걱정으로신체 활동을 제한하거나 우울, 불안과 같은 심리적 고통을 겪으며11)12) 직업을 갖지 못하는 등,13) 직접적인 의료 비용뿐만 아니라 장기적인 삶의 질 저하 및 사회적·경제적 손실도 매우크다고 할 수 있다.14) NCCD 환자들의 경우 통증을 비롯한 신체적 감각에 대한과각성(hypervigilance) 및 과도한 집중(excessive attention) 과 같은 부적응적 인지 조절을 보이는 경향이 있으며, 이는과호흡 등의 신체적·정신적 반응으로 나타나고,15) 이러한 반응은 흉통을 더욱 악화시키는 것으로 알려져 있다.16) 이에 따라, NCCD 환자의 부적응적 인지 왜곡을 교정하기 위한 중재법으로써 인지행동치료(cognitive behavioral therapy, CBT) 가 제안되었다. CBT는 NCCD에서 증상을 완화하고 환자의불안을 경감시키는 데에 중등도 이상의 효과를 보이는 것으로 보고되었다.16)17) 그러나 통상의 CBT는 훈련된 전문 치료인력이 필요하여 대면으로 수행되기 때문에 인력, 시간의 제한이 있고 환자들에게 경제적 부담을 주며, 환자의 치료 순응도가 떨어지는 등11) 여러 한계점을 가지고 있다. 이에, 본 연구에서는 1) NCCD에서 기존의 CBT의 효과와한계점에 대하여 문헌 고찰 및 요약하며, 2) 이를 기반으로기존 CBT의 한계점을 극복하고 보다 효과적으로 NCCD 환자에게 적용될 수 있는 컴퓨터 기반의 CBT 기법을 소개하고자 한다.
Abstract
Since non-cardiac chest discomfort (NCCD) can result in substantial healthcare burden and lower quality of life, interventions such as cognitive behavioral therapy (CBT) have been investigated for the relief of NCCD. In this review, we aimed to summarize the evidence on the efficacy of the CBT for the treatment of NCCD while introducing a newly-developed computerized CBT program for NCCD. Studies applying CBT to individuals with NCCD were searched for from both English and Korean electronic databases. Among 37 studies, 11 randomized controlled trials, 4 case-control studies, 1 case series, and 2 review articles were eligible for this review. Efficacy of conventional CBT for NCCD was shown in a series of studies as most of them reported improved symptom severity of NCCD or NCCD-related anxiety. However, a substantial variability existed among these studies in participants, treatment procedures and durations. High attrition rates were also reported in these studies on conventional CBT. Computerized CBT could be an alternative to the conventional CBT as it can be standardized and more easily accessible, but it was only reported in one previous study. In addition to the literature review, we presented a newly-developed computerized CBT program for NCCD which may overcome some of the limitations of conventional CBT. A computerized CBT could be an alternative treatment of NCCD, however, need further studies on its usefulness.
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